Despite recent advances and lots of passionate campaigning, there\u2019s still a long way to go before everyone who needs naloxone has easy access to it. DDN talks to a couple of early pioneers about the ongoing struggle provide this life-saving drug. \u2018The distribution of naloxone to opiate misusers should be seriously considered for trial and evaluation. While the problem of heroin misuse grows worldwide, the problem of deaths from accidental overdose is a problem we can address today. We have the opportunity to gather great potential health gains from tools already in our hands.\u2019 So said a BMJ editorial co-authored by Professor John Strang \u2013 exactly a quarter of a century ago. The June 1996 article covers the points \u2013 not least naloxone\u2019s \u2018negligible\u2019 potential for misuse \u2013 that have been debated endlessly since, and concludes by saying \u2018We may even wish to consider its legal status so it could be sold over the counter by community pharmacists\u2019. A national naloxone and overdose awareness campaign is using posters of people personally affected by overdose on posters all over the country. If you spot one, take a picture and tag @TalkingDrugs and @Release_drugs and they will share it on their socials. See the full range of posters at naloxone.org.uk Yet despite much energetic campaigning \u2013 and spiralling drug death rates \u2013 we\u2019re still a long way from that, or even from naloxone being in the hands of everyone who needs it. First developed in the 1960s, naloxone has been used to reverse opioid overdose by emergency services for more than 40 years, and in 2005 was made available under UK law to be administered by anyone for the purpose of saving a life. Despite the ongoing battle for coverage, the recent launch of a landmark national naloxone campaign using posters of people with lived experience to spread awareness and challenge stigma (DDN, May, pages 5 and 12) is a measure of how mainstream the naloxone message is now becoming. We've come a long way Philippe Bonnet \u2018It\u2019s come along leaps and bounds compared to how it used to be but for some reason there\u2019s still reluctance in some places, which I\u2019ll never understand,\u2019 peer support lead at the Hepatitis C Trust and longstanding naloxone champion, Philippe Bonnet, tells DDN. \u2018You\u2019ve got some housing providers who still don\u2019t want naloxone on their premises, for example. It doesn\u2019t make sense to me. It\u2019s legal, so what\u2019s the problem?\u2019 Drug services in England and Scotland were promised a belated financial boost earlier this year (DDN, February, page 4), and although it won\u2019t replace the money lost through years of funding reductions, some of the cash is specifically aimed at widening naloxone provision. Ultimately, however, it\u2019s still down to individual services to persuade people to actually take the kits away with them. \u2018It\u2019s how you sell it, the same as with hep C testing and treatment,\u2019 says Bonnet. \u2018We\u2019ve got people who are really vulnerable being told, \u201cYou don\u2019t want naloxone do you?\u201d and they\u2019ll say, \u201cNah, I\u2019m alright\u201d and off they go. I think local authorities could put so much more pressure on services where there\u2019s been a death. It needs to be investigated properly \u2013 \u201chow could we have averted this? Did they have naloxone? Why not?\u201d If it says \u2018naloxone offer refused\u2019 on the note and nothing else, that\u2019s not good enough. People allergic to peanuts don\u2019t tend to refuse EpiPens, do they?\u2019 Something that\u2019s always been critical is having the right local champions in place, he stresses. \u2018Somebody asked me how many kits I\u2019d given out over the years \u2013 I had to think but I reckon it\u2019s got to be 3,000 at least, and I must have trained 10,000 staff. That\u2019s just me, so national coverage really shouldn\u2019t be a problem. It\u2019s about getting the right people on board who can fight your battle.\u2019 Early champions Another early champion is harm reduction campaigner and former GP Judith Yates, who first came across naloxone in 2009 when David Best and others were working on an early paper. This studied around 70 people who were trained in overdose recognition and management and then followed up six months later after being given naloxone. \u2018Some of my patients got the kits,\u2019 she tells DDN. \u2018I remember one lad in particular, whose friend had died in his flat \u2013 he\u2019d called an ambulance, tried CPR, done everything right. He later came back to my surgery waving a naloxone kit, and we both realised that if he\u2019d had it at the time his friend would still be alive.\u2019 Following the paper\u2019s publication \u2013 Can we prevent drug-related deaths by training opioid users to recognise and manage overdoses? \u2013 the feeling among Yates and her colleagues was that it would inevitably lead to a \u2018big national roll out\u2019, she says. \u2018Nothing happened. Then in 2012 we decided that Birmingham should get going, and we got the first 1,000 kits out by the end of 2013, but still no one else was doing it. Ever since then it\u2019s been push, shove, push, shove, which is down to stigma, I suppose.\u2019 Could the availability of nasal naloxone make a difference in improving access? Might the fact that it doesn\u2019t involve a needle help to overcome some of those barriers? \u2018I was delighted by nasal naloxone finally getting licensed,\u2019 she says. \u2018It\u2019s such a simple thing to just squirt it up someone\u2019s nose and see them start breathing. With nasal naloxone I also think there\u2019s a case for having it available over the counter, which would also help to de-stigmatise it.\u2019 \u2018There are a couple of issues with it,\u2019 says Bonnet. \u2018The price is one, but the other is bioavailability \u2013 it\u2019s definitely not the same as intramuscular. Looking at the research, with intramuscular the bioavailability is much higher and it will stay in your system for longer. Having said that, I know some people will prefer it, especially a layperson. Service users won\u2019t care \u2013 they inject anyway \u2013 but people like hostel staff may well prefer it, so it definitely has its place.\u2019 Game Changer Nasal naloxone has also been a \u2018game changer\u2019 for the police, says Yates \u2013 \u2018they don\u2019t want to be waving needles around\u2019. However, while more and more forces are now running pilots and embracing naloxone\u2019s potential (DDN, May, page 13) the issue is not without controversy. The Police Federation has expressed concerns about officers \u2018being turned into paramedics\u2019, while chair of the West Midlands Police Federation recently told Newsnight he was worried about members \u2018being subject to lengthy and stressful investigations\u2019 if someone still dies after naloxone is administered. \u2018I remember a case five or six years ago where a police officer did CPR, broke a rib and got sued, so I can understand them being wary,\u2019 says Bonnet. \u2018But if you say, \u201cWhat if the guy dies?\u201d \u2013 well, if he\u2019s going to die he\u2019s going to die. Don\u2019t you want to try to prevent that?\u2019 \u2018It\u2019s only the Police Federation who tend to say these things,\u2019 adds Yates. \u2018There\u2019s no resistance from ordinary police \u2013 they\u2019re the ones who find themselves in a car park with somebody blue at their feet and they\u2019ve got to start doing CPR, call an ambulance and wait there. The police here in Birmingham have embraced it fully \u2013 they can save someone\u2019s life and they don\u2019t have to do fatal accident reports.\u2019 On that note, it\u2019s often been pointed out that \u2013 even putting aside every argument about compassion \u2013 naloxone makes sense purely on financial terms. It\u2019s far cheaper to save someone\u2019s life than for them to die, as more and more people are doing, year-on-year. \u2018In our drug-related death group meetings in Birmingham I always flag up the cases of people who\u2019ve been found unconscious but have then died in hospital of a heroin overdose,\u2019 says Yates. \u2018All of them could still be alive today if the person who\u2019d called the ambulance had given them naloxone. Lots of my patients over the years who I see walking down the street, they wouldn\u2019t be here otherwise. Now they\u2019re with their families and getting on with their lives.\u2019 Getting past the stigma From a GP perspective, Yates has previously been exasperated that people happy to prescribe methadone and buprenorphine still wouldn\u2019t prescribe naloxone (DDN, July\/August 2015, page 15). \u2018GPs give out EpiPens hand over fist to anyone who\u2019s got a peanut allergy, but do they give out naloxone kits to everyone at risk of opiate overdose?\u2019 she says. \u2018No, they don\u2019t.\u2019 So how optimistic is she that we\u2019ll soon be able to get it into the hands of everyone who needs it? \u2018You need to have it with you, so even once you get past the stigma you\u2019re never going to get 100 per cent cover. But there\u2019s certainly scope for getting an awful lot more out there. It\u2019s frustrating because it\u2019s absolutely the only medicine of its kind that saves lives so quickly and cheaply. I can only think it\u2019s because people have mixed feelings about people who use drugs, and whether they live or die. And sadly, of course, some people who use drugs can have mixed feelings about whether they live or die as well \u2013 they can take a Russian roulette attitude. But I\u2019ve been working in this field long enough to see people come out of that pit and get on to enjoy the second half of their lives in their 30s, 40s, 50s. So never give up. \u2018There is no other medicine like naloxone,\u2019 she states. \u2018There\u2019s nothing in the whole pharmacopeia that saves a life in two minutes with no side effects and no contraindications. If someone has a heroin overdose they don\u2019t need to die, and yet we\u2019re still having these conversations. We\u2019ll just have to keep nagging.\u2019 This article has been produced with support from Ethypharm, which has not influenced the content in any way.